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Vol. 110. Issue 5.
Pages 372-384 (June 2019)
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Vol. 110. Issue 5.
Pages 372-384 (June 2019)
Original Article
DOI: 10.1016/j.adengl.2018.10.025
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Behaviors, Attitudes, and Knowledge Related to Sun Exposure Among Medical Students at the Universidad de Las Palmas de Gran Canaria
Comportamientos, actitudes y conocimientos relacionados con la exposición solar en estudiantes de medicina de la Universidad de Las Palmas de Gran Canaria
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S. Poncea,
Corresponding author
sauloponce90@gmail.com

Corresponding author.
, A. Jódara, L. Borregoa, P. Saavedrab
a Servicio de Dermatología, Complejo Hospitalario Universitario Insular Materno Infantil, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
b Departamento de Matemáticas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Statistics
Tables (3)
Table 1. Characteristics of the Participants and Questionnaire Responses.a
Table 2. Characteristics of the Students by Number of Sunburn Episodes.a
Table 3. Multivariate Logistic Regression.
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Additional material (1)
Abstract
Introduction

The incidence of skin cancer, for which the main risk factor is exposure to ultraviolet radiation, has risen worldwide. Sunburn is one of the simplest ways to assess sun exposure habits. To date, few studies have evaluated sun exposure in university students.

Objectives

To determine behaviors, attitudes, and knowledge related to sun exposure and sun protection measures among medical students at the Universidad de Las Palmas de Gran Canaria; and to assess their relation to sunburn frequency.

Material and Methods

The voluntary participants in this cross-sectional survey were first-, third- and sixth-year university students enrolled during the 2016–2017 academic year. The students responded to a validated questionnaire about their habits, attitudes, and knowledge in relation to sun exposure. Respondents were grouped according to the number of sunburns they had experienced during the previous summer.

Results

A total of 286 students responded. The students demonstrated a high level of knowledge, but the percentage who experienced a sunburn was high. Multivariate analysis showed independent correlations between experiencing a sunburn and age, male sex, academic year of enrollment at the time of the survey, phototype, and negative attitudes toward the use of sun protection measures.

Conclusions

Our medical students’ level of knowledge about sun exposure and sun protection is high and scarcely varies with time spent at the university. However, their knowledge is not reflected in their behavior and attitudes or in the frequency of sunburns.

Keywords:
Sun exposure
Sun protection
Habits
Knowledge
Attitude
Survey
Sunburn
University student
Resumen
Introducción

En las últimas décadas se ha producido un aumento en la incidencia de cáncer de piel a nivel mundial, siendo la exposición a la radiación ultravioleta el principal factor de riesgo. La quemadura solar es uno de los parámetros más sencillos para valorar los hábitos de exposición solar. Actualmente existen pocos trabajos que evalúen la fotoexposición en la población universitaria.

Objetivos

Determinar los comportamientos, actitudes y conocimientos sobre fotoexposición y fotoprotección en estudiantes de medicina de la Universidad de Las Palmas de Gran Canaria y su relación con la quemadura solar.

Material y métodos

Se realizó un estudio trasversal mediante participación voluntaria de alumnos de 1.°, 3.° y 6.° matriculados en el curso 2016-2017. Se utilizó un cuestionario validado sobre hábitos, actitudes y conocimientos en exposición solar. Se agruparon según el número de quemaduras solares en el último verano.

Resultados

Participaron 286 alumnos. Si bien los estudiantes mostraron un elevado nivel de conocimiento, se observó un alto porcentaje de quemaduras (70,6%). Tras el análisis multivariante las variables que mostraron una asociación independiente con las quemaduras fueron la edad, el sexo masculino, el curso matriculado, el fototipo y las actitudes negativas con respecto al empleo de fotoprotectores.

Conclusiones

En nuestro ámbito el nivel de conocimientos que presentan los estudiantes de medicina sobre fotoexposición y fotoprotección apenas varía durante la carrera y, a pesar de ser alto, no se refleja en su comportamiento, actitudes ni en la frecuencia de quemaduras solares.

Palabras clave:
Fotoexposición
Fotoprotección
Hábito
Conocimiento
Actitud
Cuestionario
Quemadura solar
Universitario
Full Text
Background

?Skin cancer refers to a group of tumors with different characteristics and origins, which can be categorized into 2 major groups: melanoma and nonmelanoma skin cancer. In recent decades, the incidence of skin cancer has risen in Spain, Europe, and worldwide.1–6 While there are several risk factors, the main cause is still exposure to ultraviolet radiation, especially when there is a history of high accumulated sun exposure and episodes of sunburn during childhood and adolescence.1,5,7 Consequently, a history of sunburn is one of the parameters most often used in epidemiological studies to assess sun exposure behaviors, especially in patients with melanoma.8

In Spain, knowledge and attitudes related to sun exposure habits and sun protection behaviors have been studied mainly in adolescents and in populations living near beaches along the eastern and southern seaboards of the Iberian penninsula.8–13 There is little data on this topic from the university population,12 and no validated data is available on the sun exposure habits of people living in the Canary Islands. Questionnaires are the instruments usually used to investigate health-related behaviors; they can be used in population studies and to assess the impact of interventions that have been implemented in the general population.9 Medical students are a group in which we can assess attitudes, knowledge, and behaviors in a population with a high level of knowledge about carcinogenesis, making them an ideal study population when our aim is to determine whether having such knowledge influences the individual's sun exposure habits and photoprotection behavior or has an impact on the frequency of sunburn.

MethodologyStudy Design and Population

We conducted a cross-sectional descriptive study in a group of first-, third-, and sixth-year students enrolled in the 2016-2017 academic year in the medical degree program at the University of Las Palmas de Gran Canaria.

Questionnaire

The questionnaire used was the Cuestionario a pie de playa (The Beach Questionnaire),9 validated by De Troya-Martín et al., which comprised sections on personal information (4 items), skin color (1 item), skin phototype (1 item), sunbathing behaviors at the beach (3 items), sunburn from beach exposure, sun protection behaviors at the beach (7 items), attitudes toward sun exposure (14 items), and knowledge related to sun exposure (7 items) (see additional material).

Sunburn was defined as the presence of pain and redness in the skin for more than 12hours following exposure to the sun.9 Attitude was defined as a consistently positive or negative general feeling.9 We explored attitudes in 3 dimensions: health, appearance, and pleasure/leisure concerns.

The students completed the questionnaire voluntarily on the Moodle platform of the virtual campus at the University of Las Palmas de Gran Canaria. The data were then exported in an Excel format and anonymized for the rest of the study. All the data were used and stored in accordance with Spanish legislation on data protection (Ley 41/2002 of 14 November and Ley 15/1999 of 15 December) and the study was approved by the ethics committee of the Complejo Hospitalario Universitario Insular-Materno Infantil (Las Palmas de Gran Canaria, Spain).

Statistical Analysis

Age was summarized as means and standard deviations. Categorical variables were expressed in terms of frequencies and percentages. Means were compared using the independent t test, and percentages with the Chi-squared test, the linear-by-linear association test, or Fisher's exact test, as appropriate. To compare the group with no sunburn episodes with those reporting 1 to 2 episodes and those reporting 3 or more episodes, we performed 2 multivariate logistc regression analyses using the variables that were significant in the univariate analysis according to the complete selection algorithm and the Bayesian information criterion. Both models were summarized using P values ()and odds ratios (OR) with 95% confidence intervals. The significance threshold was set .05. The data were analyzed using the R package, version 3.1.1 (R Development Core Team, 2016).14,15

Results

In total, 286 of the 411 students in the course completed the questionnaire: 74 (59.2%) were first-year students, 129 (81.1%) were in their third year, and 83 (65.4%) were in the sixth year of their medical studies. Two participants failed to complete the questionnaire and the unanswered questions were treated as lost values.

Descriptive Analysis

Table 1 shows the demographic characteristics of the respondents and the responses grouped by sex.

Table 1.

Characteristics of the Participants and Questionnaire Responses.a

  Total  Men  Women   
  N=286  N=89  N=197  P 
Age, y (SD)  21.3 (3.4)  21.7 (4.4)  21.1 (2.9)  .184 
Country of origin        .693 
Spain  278 (97.2)  86 (96.6)  192 (97.5)   
Other  8 (2.8)  3 (3.4)  5 (2.5)   
Time resident in the Canary Islands        .339 
From birth  273 (95.5)  83 (93.3)  190 (96.4)   
Arrived aged 10 years or older  8 (2.8)  3 (3.4)  5 (2.5)   
Temporary (2-12 months)  5 (1.7)  3 (3.4)  2 (1.0)   
1. Skin color        .065 
Very fair  43 (15.0)  6 (6.7)  37 (18.8)   
Fair  119 (41.6)  40 (44.9)  79 (40.1)   
Olive  67 (23.4)  22 (24.7)  45 (22.8)   
2. Skin phototype        .197 
Phototype I  41 (14.3)  12 (13.5)  29 (14.7)   
Phototype II  58 (20.3)  17 (19.1)  41 (20.8)   
Phototype III  117 (40.9)  44 (49.4)  73 (37.1)   
Phototype IV  70 (24.5)  16 (18.0)  54 (27.4)   
3. No of sunny days spent at the beach        .182 
None  6 (2.1)  1 (1.1)  5 (2.5)   
1-5 days  34 (11.9)  15 (16.9)  19 (9.6)   
6-15 days  63 (22.0)  22 (24.7)  41 (20.8)   
16-30 days  79 (27.6)  26 (29.2)  53 (26.9)   
Over 30 days  104 (36.4)  25 (28.1)  79 (40.1)   
4. Time exposed to sun on beach        .552 
Less than 30 minutes  23 (8.0)  5 (5.6)  18 (9.1)   
30 min-1 hour  51 (17.8)  18 (20.2)  33 (16.8)   
1-3 hours  116 (40.6)  39 (43.8)  77 (39.1)   
Over 3 hours  96 (33.6)  27 (30.3)  69 (35.0)   
5. Time spent in sun during midday hours        .372 
None  24 (8.4)  8 (9.0)  16 (8.1)   
Less than 1 hour  101 (35.3)  35 (39.3)  66 (33.5)   
1-2 hours  95 (33.2)  30 (33.7)  65 (33.0)   
2-4 hours  59 (20.6)  16 (18.0)  43 (21.8)   
4-6 hours  7 (2.4)  0 (0.0)  7 (3.6)   
6. Sunburn episodes        .023 
None  84 (29.4)  17 (19.1)  67 (34.0)   
1-2  150 (52.4)  49 (55.1)  101 (51.3)   
3-5  45 (15.7)  19 (21.3)  26 (13.2)   
6-10  6 (2.1)  4 (4.5)  2 (1.0)   
> 10  1 (0.3)  0 (0.0)  1 (0.5)   
7. I use a beach umbrella        .238 
Never  45 (15.7)  16 (18.0)  29 (14.7)   
Rarely  58 (20.3)  24 (27.0)  34 (17.3)   
Sometimes  72 (25.2)  21 (23.6)  51 (25.9)   
Usually  74 (25.9)  20 (22.5)  54 (27.4)   
Always  37 (12.9)  8 (9.0)  29 (14.7)   
8. I wear sunglasses        .207 
Never  32 (11.2)  9 (10.1)  23 (11.7)   
Rarely  36 (12.6)  16 (18.0)  20 (10.2)   
Sometimes  53 (18.6)  18 (20.2)  35 (17.9)   
Usually  89 (31.2)  29 (32.6)  60 (30.6)   
Always  75 (26.3)  17 (19.1)  58 (29.6)   
9. I wear a a sun hat or a cap        .011 
Never  88 (30.9)  33 (37.1)  55 (28.1)   
Rarely  88 (30.9)  32 (36.0)  56 (28.6)   
Sometimes  57 (20.0)  17 (19.1)  40 (20.4)   
Usually  34 (11.9)  2 (2.2)  32 (16.3)   
Always  18 (6.3)  5 (5.6)  13 (6.6)   
10. I wear long sleeves or long pants        .118 
Never  136 (47.7)  40 (44.9)  96 (49.0)   
Rarely  56 (19.6)  22 (24.7)  34 (17.3)   
Sometimes  60 (21.1)  14 (15.7)  46 (23.5)   
Usually  29 (10.2)  10 (11.2)  19 (9.7)   
Always  4 (1.4)  3 (3.4)  1 (0.5)   
11. I avoid the sun between midday and 16.00 h        .598 
Never  16 (5.6)  3 (3.4)  13 (6.6)   
Rarely  68 (23.9)  24 (27.0)  44 (22.4)   
Sometimes  106 (37.2)  36 (40.4)  70 (35.7)   
Usually  79 (27.7)  22 (24.7)  57 (29.1)   
Always  16 (5.6)  4 (4.5)  12 (6.1)   
12. I use a sunscreen with a protection factor ≥ 15        .165 
Never  10 (3.5)  5 (5.6)  5 (2.6)   
Rarely  7 (2.5)  3 (3.4)  4 (2.0)   
Sometimes  30 (10.5)  14 (15.7)  16 (8.2)   
Usually  41 (14.4)  11 (12.4)  30 (15.3)   
Always  197 (69.1)  56 (62.9)  141 (71.9)   
13. I use a sunscreen with a protection factor ≥ 50        .045 
Never  28 (9.8)  13 (14.6)  15 (7.7)   
Rarely  38 (13.3)  13 (14.6)  25 (12.8)   
Sometimes  49 (17.2)  18 (20.2)  31 (15.8)   
Usually  79 (27.7)  27 (30.3)  52 (26.5)   
Always  91 (31.9)  18 (20.2)  73 (37.2)   
14. When I have a tan, clothes look better on me        <.001 
Strongly agree  73 (25.6)  10 (11.2)  63 (32.1)   
Agree  110 (38.6)  35 (39.3)  75 (38.3)   
Neutral  92 (32.3)  40 (44.9)  52 (26.5)   
Disagree  5 (1.8)  3 (3.4)  2 (1.0)   
Strongly disagree  5 (1.8)  1 (1.1)  4 (2.0)   
15. Sunbathing helps prevent health problems        .245 
Strongly agree  18 (6.3)  6 (6.7)  12 (6.1)   
Agree  152 (53.3)  40 (44.9)  112 (57.1)   
Neutral  52 (18.2)  21 (23.6)  31 (15.8)   
Disagree  48 (16.8)  15 (16.9)  33 (16.8)   
Strongly disagree  15 (5.3)  7 (7.9)  8 (4.1)   
16. I like how the sun feels on my skin when I’m lying on the beach        .589 
Strongly agree  66 (23.2)  17 (19.1)  49 (25.0)   
Agree  126 (44.2)  40 (44.9)  86 (43.9)   
Neutral  51 (17.9)  15 (16.9)  36 (18.4)   
Disagree  26 (9.1)  10 (11.2)  16 (8.2)   
Strongly disagree  16 (5.6)  7 (7.9)  9 (4.6)   
17.It is worth using sunscreens to prevent future problems        .148 
Strongly agree  266 (93.3)  80 (89.9)  186 (94.9)   
Agree  17 (6.0)  7 (7.9)  10 (5.1)   
Neutral  1 (0.4)  1 (1.1)  0 (0.0)   
Strongly disagree  1 (0.4)  1 (1.1)  0 (0.0)   
18. I find sunscreen creams disagreeable        .117 
Strongly agree  14 (4.9)  8 (9.0)  6 (3.1)   
Agree  42 (14.7)  16 (18.0)  26 (13.3)   
Neutral  55 (19.3)  16 (18.0)  39 (19.9)   
Disagree  90 (31.6)  22 (24.7)  68 (34.7)   
Strongly disagree  84 (29.5)  27 (30.3)  57 (29.1)   
19. It is worth taking the trouble to use sunscreen even if it stops me from tanning        .366 
Strongly agree  192 (67.4)  58 (65.2)  134 (68.4)   
Agree  75 (26.3)  22 (24.7)  53 (27.0)   
Neutral  14 (4.9)  7 (7.9)  7 (3.6)   
Disagree  4 (1.4)  2 (2.2)  2 (1.0)   
20. People with tans are more attractive        .502 
Strongly agree  28 (9.8)  10 (11.2)  18 (9.2)   
Agree  87 (30.5)  32 (36.0)  55 (28.1)   
Neutral  134 (47.0)  39 (43.8)  95 (48.5)   
Disagree  25 (8.8)  5 (5.6)  20 (10.2)   
21. Sunbathing is healthy for my body        .410 
Strongly agree  21 (7.4)  8 (9.0)  13 (6.6)   
Agree  161 (56.5)  43 (48.3)  118 (60.2)   
Neutral  64 (22.5)  24 (27.0)  40 (20.4)   
Disagree  35 (12.3)  12 (13.5)  23 (11.7)   
Strongly disagree  4 (1.4)  2 (2.2)  2 (1.0)   
22. Sunbathing relaxes me        .750 
Strongly agree  75 (26.4)  19 (21.6)  56 (28.6)   
Agree  129 (45.4)  42 (47.7)  87 (44.4)   
Neutral  47 (16.5)  17 (19.3)  30 (15.3)   
Disagree  24 (8.5)  7 (8.0)  17 (8.7)   
Strongly disagree  9 (3.2)  3 (3.4)  6 (3.1)   
23. A tan makes me look younger and more relaxed        .953 
Strongly agree  29 (10.2)  8 (9.1)  21 (10.7)   
Agree  75 (26.4)  25 (28.4)  50 (25.5)   
Neutral  107 (37.7)  34 (38.6)  73 (37.2)   
Disagree  51 (18.0)  14 (15.9)  37 (18.9)   
Strongly disagree  22 (7.7)  7 (8.0)  15 (7.7)   
24. Sunbathing makes me feel better        .760 
Strongly agree  59 (20.8)  18 (20.5)  41 (20.9)   
Agree  123 (43.3)  35 (39.8)  88 (44.9)   
Neutral  76 (26.8)  28 (31.8)  48 (24.5)   
Disagree  16 (5.6)  4 (4.5)  12 (6.1)   
Strongly disagree  10 (3.5)  3 (3.4)  7 (3.6)   
25. I like sunbathing        .069 
Strongly agree  85 (29.9)  20 (22.7)  65 (33.2)   
Agree  118 (41.5)  34 (38.6)  84 (42.9)   
Neutral  51 (18.0)  24 (27.3)  27 (13.8)   
Disagree  21 (7.4)  7 (8.0)  14 (7.1)   
Strongly disagree  9 (3.2)  3 (3.4)  6 (3.1)   
26. When I am on the beach I prefer to be in the shade        .707 
Strongly agree  36 (12.7)  8 (9.1)  28 (14.3)   
Agree  75 (26.4)  26 (29.5)  49 (25.0)   
Neutral  86 (30.3)  28 (31.8)  58 (29.6)   
Disagree  82 (28.9)  25 (28.4)  57 (29.1)   
Strongly disagree  5 (1.8)  1 (1.1)  4 (2.0)   
27. I dislike high protection factor sunscreens because they look unattractive        .656 
         
Strongly agree  2 (0.7)  1 (1.1)  1 (0.5)   
Agree  17 (6.0)  5 (5.7)  12 (6.1)   
Neutral  53 (18.7)  20 (22.7)  33 (16.8)   
Disagree  90 (31.7)  29 (33.0)  61 (31.1)   
Strongly disagree  122 (43.0)  33 (37.5)  89 (45.4)   
28. Sunscreens prevent skin aging caused by exposure to the ultraviolet radiation in sunlight        .038 
False  51 (18.0)  22 (25.0)  29 (14.8)   
True  233 (82.0)  66 (75.0)  167 (85.2)   
29. Sun exposure is the leading cause of skin cancer        .660 
False  5 (1.8)  2 (2.3)  3 (1.5)   
True  279 (98.2)  86 (97.7)  193 (98.5)   
30. The sun can cause spots on the skin        .342 
False  2 (0.7)  0 (0.0)  2 (1.0)   
True  282 (99.3)  88 (100.0)  194 (99.0)   
31. If I use a total-protection sunscreen (sunblock) I can stay in the sun all day without any risk        .015 
False  271 (95.4)  80 (90.9)  191 (97.4)   
True  13 (4.6)  8 (9.1)  5 (2.6)   
32. Avoiding the sun during the middle of the day (between 12 and 4 pm) is the most effective way to protect the skin        .336 
False  40 (14.1)  15 (17.0)  25 (12.8)   
True  244 (85.9)  73 (83.0)  171 (87.2)   
33. Avoiding sun exposure when you are young (before 18 years of age) reduces the risk of skin cancer by 80%        .645 
False  86 (30.3)  25 (28.4)  61 (31.1)   
True  198 (69.7)  63 (71.6)  135 (68.9)   
34. Once my skin is tanned, I do not need to use sunscreen        .342 
False  282 (99.3)  88 (100.0)  194 (99.0)   
True  2 (0.7)  0 (0.0)  2 (1.0)   
a

The data are expressed as means (SD) and frequencies (%).

In total, 70.5% of the participants reported at least 1 sunburn in the previous summer, more men than women (P=.023); 69.1% of students said that they always used a sunscreen with a sun protection factor (SPF) of 15 or more. Of note was the more frequent use among women of sunscreens with an SPF of 50 or higher (P=.045).

Over half of the respondents expressed favorable attitudes towards sun exposure in most of the statements, with the exception of the statements related to the use of sun protection. Women expressed more agreement with the statement “When I have a tan, clothes look better on me” (P <.001). The answers in the section on attitudes changed very little by academic year.

The percentage of correct answers in the knowledge section was over 80% for all the statements except “Avoiding sun exposure when you are young (before 18 years of age) reduces the risk of skin cancer by 80%” (69.7%). Women were more knowledgeable than men about the use of sunscreens; they had a significantly higher number of correct answers than men in the following statements: “Sunscreens prevent skin aging caused by the ultraviolet radiation in sunlight” (P=.038) and “If I use a total protection sunscreen I can stay in the sun all day without risk” (P=.015). The responses in the knowledge section did not vary by academic year.

Univariate Analysis

Table 2 summarizes the study variables for all students by sunburn frequency.

Table 2.

Characteristics of the Students by Number of Sunburn Episodes.a

  Totaln=286  Nonen=84  1-2n=150  ≥ 3n=52  P 
Age, y (SD)  21.3 (3.4)  22.5 (3.9)  20.9 (3.1)  20.3 (2.9)  <.001 
Academic year          <.001b 
1st  74 (25.9)  14 (16.7)  38 (25.3)  22 (42.3)   
3rd  129 (45.1)  29 (34.5)  77 (51.3)  23 (44.2)   
6th  83 (29.0)  41 (48.8)  35 (23.3)  7 (13.5)   
Sex          .003b 
Man  89 (31.1)  17 (20.2)  49 (32.7)  23 (44.2)   
Woman  197 (68.9)  67 (79.8)  101 (67.3)  29 (55.8)   
Country of origin          .259 
Spain  278 (97.2)  80 (95.2)  146 (97.3)  52 (100.0)   
Other  8 (2.8)  4 (4.8)  4 (2.7)  0 (0.0)   
Time resident in the Canary Islands          .706 
From birth  273 (95.5)  80 (95.2)  142 (94.7)  51 (98.1)   
After age 10  8 (2.8)  3 (3.6)  4 (2.7)  1 (1.9)   
Temporary (2-12 months)  5 (1.7)  1 (1.2)  4 (2.7)  0 (0.0)   
1. Skin color          .125 
Very fair  43 (15.0)  12 (14.3)  24 (16.0)  7 (13.5)   
Fair  119 (41.6)  29 (34.5)  59 (39.3)  31 (59.6)   
Olive  67 (23.4)  23 (27.4)  36 (24.0)  8 (15.4)   
Dark  57 (19.9)  20 (23.8)  31 (20.7)  6 (11.5)   
2. Skin phototype          <.001 
Phototype I  41 (14.3)  9 (10.7)  19 (12.7)  13 (25.0)   
Phototype II  58 (20.3)  13 (15.5)  28 (18.7)  17 (32.7)   
Phototype III  117 (40.9)  31 (36.9)  67 (44.7)  19 (36.5)   
Phototype IV  70 (24.5)  31 (36.9)  36 (24.0)  3 (5.8)   
3. No of sunny days at beach          .148 
None  6 (2.1)  2 (2.4)  1 (0.7)  3 (5.8)   
1-5 days  34 (11.9)  11 (13.1)  19 (12.7)  4 (7.7)   
6-15 days  63 (22.0)  18 (21.4)  32 (21.3)  13 (25.0)   
16-30 days  79 (27.6)  17 (20.2)  43 (28.7)  19 (36.5)   
More than 30 days  104 (36.4)  36 (42.9)  55 (36.7)  13 (25.0)   
4. Time spent in the sun on beach          0.515 
Less than 30 minutes  23 (8.0)  6 (7.1)  11 (7.3)  6 (11.5)   
30 min-1 hour  51 (17.8)  18 (21.4)  27 (18.0)  6 (11.5)   
1-3 hours  116 (40.6)  30 (35.7)  60 (40.0)  26 (50.0)   
Over 3 hours  96 (33.6)  30 (35.7)  52 (34.7)  14 (26.9)   
5. Time spent sunbathing during the middle of the day          .268 
None  24 (8.4)  11 (13.1)  11 (7.3)  2 (3.8)   
Less than 1 hour  101 (35.3)  35 (41.7)  50 (33.3)  16 (30.8)   
1-2 hours  95 (33.2)  20 (23.8)  53 (35.3)  22 (42.3)   
2-4 hours  59 (20.6)  17 (20.2)  31 (20.7)  11 (21.2)   
4-6 hours  7 (2.4)  1 (1.2)  5 (3.3)  1 (1.9)   
7. I use a beach umbrella          .378 
Never  45 (15.7)  13 (15.5)  24 (16.0)  8 (15.4)   
Rarely  58 (20.3)  18 (21.4)  28 (18.7)  12 (23.1)   
Sometimes  72 (25.2)  16 (19.0)  40 (26.7)  16 (30.8)   
Usually  74 (25.9)  20 (23.8)  41 (27.3)  13 (25.0)   
Always  37 (12.9)  17 (20.2)  17 (11.3)  3 (5.8)   
8. I wear sunglasses          .606 
Never  32 (11.2)  7 (8.3)  17 (11.4)  8 (15.4)   
Rarely  36 (12.6)  10 (11.9)  18 (12.1)  8 (15.4)   
Sometimes  53 (18.6)  16 (19.0)  26 (17.4)  11 (21.2)   
Usually  89 (31.2)  26 (31.0)  45 (30.2)  18 (34.6)   
Always  75 (26.3)  25 (29.8)  43 (28.9)  7 (13.5)   
9. I wear a sun hat or cap          .626 
Never  88 (30.9)  24 (28.6)  46 (30.9)  18 (34.6)   
Rarely  88 (30.9)  22 (26.2)  47 (31.5)  19 (36.5)   
Sometimes  57 (20.0)  17 (20.2)  31 (20.8)  9 (17.3)   
Usually  34 (11.9)  14 (16.7)  15 (10.1)  5 (9.6)   
Always  18 (6.3)  7 (8.3)  10 (6.7)  1 (1.9)   
10. I wear long sleeves or long trousers          .064 
Never  136 (47.7)  35 (41.7)  79 (53.0)  22 (42.3)   
Rarely  56 (19.6)  12 (14.3)  29 (19.5)  15 (28.8)   
Sometimes  60 (21.1)  25 (29.8)  27 (18.1)  8 (15.4)   
Usually  29 (10.2)  9 (10.7)  13 (8.7)  7 (13.5)   
Always  4 (1.4)  3 (3.6)  1 (0.7)  0 (0.0)   
11. I avoid the sun between 12 and 4 pm          .458 
Never  16 (5.6)  4 (4.8)  9 (6.0)  3 (5.8)   
Rarely  68 (23.9)  18 (21.4)  36 (24.2)  14 (26.9)   
Sometimes  106 (37.2)  28 (33.3)  53 (35.6)  25 (48.1)   
Usually  79 (27.7)  27 (32.1)  43 (28.9)  9 (17.3)   
Always  16 (5.6)  7 (8.3)  8 (5.4)  1 (1.9)   
12. I use a sunscreen with a protection factor ≥ 15          .275 
Never  10 (3.5)  2 (2.4)  7 (4.7)  1 (1.9)   
Rarely  7 (2.5)  2 (2.4)  5 (3.4)  0 (0.0)   
Sometimes  30 (10.5)  12 (14.3)  12 (8.1)  6 (11.5)   
Usually  41 (14.4)  6 (7.1)  26 (17.4)  9 (17.3)   
13. I use a sunscreen with a protection factor ≥ 50          .149 
Never  28 (9.8)  5 (6.0)  18 (12.1)  5 (9.6)   
Rarely  38 (13.3)  16 (19.0)  19 (12.8)  3 (5.8)   
Sometimes  49 (17.2)  15 (17.9)  24 (16.1)  10 (19.2)   
Usually  79 (27.7)  18 (21.4)  40 (26.8)  21 (40.4)   
Always  91 (31.9)  30 (35.7)  48 (32.2)  13 (25.0)   
14. Clothes look better on me when I have a tan          .686 
Strongly agree  73 (25.6)  22 (26.2)  36 (24.2)  15 (28.8)   
Agree  110 (38.6)  29 (34.5)  64 (43.0)  17 (32.7)   
Neutral  92 (32.3)  31 (36.9)  43 (28.9)  18 (34.6)   
Disagree  5 (1.8)  0 (0.0)  4 (2.7)  1 (1.9)   
Strongly disagree  5 (1.8)  2 (2.4)  2 (1.3)  1 (1.9)   
15. Sunbathing helps prevent health problems          .622 
Strongly agree  18 (6.3)  5 (6.0)  11 (7.4)  2 (3.8)   
Agree  152 (53.3)  50 (59.5)  80 (53.7)  22 (42.3)   
Neutral  52 (18.2)  13 (15.5)  27 (18.1)  12 (23.1)   
Disagree  48 (16.8)  12 (14.3)  23 (15.4)  13 (25.0)   
Strongly disagree  15 (5.3)  4 (4.8)  8 (5.4)  3 (5.8)   
16. I like how the sun feels on my skin when I am lying on the beach          .161 
Strongly agree  66 (23.2)  22 (26.2)  35 (23.5)  9 (17.3)   
Agree  126 (44.2)  28 (33.3)  71 (47.7)  27 (51.9)   
Neutral  51 (17.9)  15 (17.9)  25 (16.8)  11 (21.2)   
Disagree  26 (9.1)  10 (11.9)  13 (8.7)  3 (5.8)   
Strongly disagree  16 (5.6)  9 (10.7)  5 (3.4)  2 (3.8)   
17. It is worth the trouble to use sunscreen to avoid problems in the future        .337 
Strongly agree  266 (93.3)  81 (96.4)  137 (91.9)  48 (92.3)   
Agree  17 (6.0)  3 (3.6)  11 (7.4)  3 (5.8)   
Neutral  1 (0.4)  0 (0.0)  1 (0.7)  0 (0.0)   
Strongly disagree  1 (0.4)  0 (0.0)  0 (0.0)  1 (1.9)   
18. Sunscreens do not feel good on my skin          .554 
Strongly agree  14 (4.9)  2 (2.4)  8 (5.4)  4 (7.7)   
Agree  42 (14.7)  11 (13.1)  24 (16.1)  7 (13.5)   
Neutral  55 (19.3)  12 (14.3)  34 (22.8)  9 (17.3)   
Disagree  90 (31.6)  31 (36.9)  41 (27.5)  18 (34.6)   
Strongly disagree  84 (29.5)  28 (33.3)  42 (28.2)  14 (26.9)   
19. It is worthwhile using sunscreeneven if I do not get a tan          <.001b 
Strongly agree  192 (67.4)  70 (83.3)  94 (63.1)  28 (53.8)   
Agree  75 (26.3)  12 (14.3)  46 (30.9)  17 (32.7)   
Neutral  14 (4.9)  2 (2.4)  6 (4.0)  6 (11.5)   
Disagree  4 (1.4)  0 (0.0)  3 (2.0)  1 (1.9)   
20. People with tans are more attractive          .906 
Strongly agree  28 (9.8)  8 (9.5)  14 (9.4)  6 (11.5)   
Agree  87 (30.5)  24 (28.6)  44 (29.5)  19 (36.5)   
Neutral  134 (47.0)  39 (46.4)  74 (49.7)  21 (40.4)   
Disagree  25 (8.8)  8 (9.5)  12 (8.1)  5 (9.6)   
Strongly disagree  11 (3.9)  5 (6.0)  5 (3.4)  1 (1.9)   
21. Sunbathing is healthy formy body          .029 
Strongly agree  21 (7.4)  4 (4.8)  14 (9.4)  3 (5.8)   
Agree  161 (56.5)  51 (60.7)  88 (59.1)  22 (42.3)   
Neutral  64 (22.5)  18 (21.4)  32 (21.5)  14 (26.9)   
Disagree  35 (12.3)  8 (9.5)  14 (9.4)  13 (25.0)   
Strongly disagree  4 (1.4)  3 (3.6)  1 (0.7)  0 (0.0)   
22. Sunbathing relaxes me          .170 
Strongly agree  75 (26.4)  19 (22.6)  40 (27.0)  16 (30.8)   
Agree  129 (45.4)  36 (42.9)  69 (46.6)  24 (46.2)   
Neutral  47 (16.5)  12 (14.3)  25 (16.9)  10 (19.2)   
Disagree  24 (8.5)  11 (13.1)  11 (7.4)  2 (3.8)   
Strongly disagree  9 (3.2)  6 (7.1)  3 (2.0)  0 (0.0)   
23. Having a tan makes me look younger and more relaxed          .144 
Strongly agree  29 (10.2)  8 (9.5)  13 (8.8)  8 (15.4)   
Agree  75 (26.4)  19 (22.6)  46 (31.1)  10 (19.2)   
Neutral  107 (37.7)  27 (32.1)  56 (37.8)  24 (46.2)   
Disagree  51 (18.0)  19 (22.6)  25 (16.9)  7 (13.5)   
Strongly disagree  22 (7.7)  11 (13.1)  8 (5.4)  3 (5.8)   
24. Sunbathing makes me feel better          .098 
Strongly agree  59 (20.8)  19 (22.6)  32 (21.6)  8 (15.4)   
Agree  123 (43.3)  29 (34.5)  71 (48.0)  23 (44.2)   
Neutral  76 (26.8)  23 (27.4)  35 (23.6)  18 (34.6)   
Disagree  16 (5.6)  6 (7.1)  8 (5.4)  2 (3.8)   
Strongly disagree  10 (3.5)  7 (8.3)  2 (1.4)  1 (1.9)   
25. I like sunbathing          .323 
Strongly agree  85 (29.9)  25 (29.8)  45 (30.4)  15 (28.8)   
Agree  118 (41.5)  31 (36.9)  65 (43.9)  22 (42.3)   
Neutral  51 (18.0)  16 (19.0)  23 (15.5)  12 (23.1)   
Disagree  21 (7.4)  6 (7.1)  13 (8.8)  2 (3.8)   
Strongly disagree  9 (3.2)  6 (7.1)  2 (1.4)  1 (1.9)   
26. When I am on the beach I prefer to sit in the shade          .627 
Strongly agree  36 (12.7)  15 (17.9)  15 (10.1)  6 (11.5)   
Agree  75 (26.4)  21 (25.0)  42 (28.4)  12 (23.1)   
Neutral  86 (30.3)  24 (28.6)  42 (28.4)  20 (38.5)   
Disagree  82 (28.9)  22 (26.2)  46 (31.1)  14 (26.9)   
27. I dislike high protection factor sunscreens because they look unattractive          <.001b 
Strongly agree  2 (0.7)  0 (0.0)  1 (0.7)  1 (1.9)   
Agree  17 (6.0)  4 (4.8)  11 (7.4)  2 (3.8)   
Neutral  53 (18.7)  9 (10.7)  27 (18.2)  17 (32.7)   
Disagree  90 (31.7)  23 (27.4)  48 (32.4)  19 (36.5)   
Strongly disagree  122 (43.0)  48 (57.1)  61 (41.2)  13 (25.0)   
28. Sunscreens prevent skin aging caused by exposure to the ultraviolet radiation in sunlight          .031 
False  51 (18.0)  9 (10.7)  35 (23.6)  7 (13.5)   
True  233 (82.0)  75 (89.3)  113 (76.4)  45 (86.5)   
29. Sun exposure is the leading cause of skin cancer          .321 
False  5 (1.8)  0 (0.0)  4 (2.7)  1 (1.9)   
True  279 (98.2)  84 (100.0)  144 (97.3)  51 (98.1)   
30. Exposure to sunlight causes spots on the skin          .396 
False  2 (0.7)  0 (0.0)  2 (1.4)  0 (0.0)   
True  282 (99.3)  84 (100.0)  146 (98.6)  52 (100.0)   
31. If I use a total sunblock I can stay in the sun all day without risk          .486 
False  271 (95.4)  81 (96.4)  142 (95.9)  48 (92.3)   
True  13 (4.6)  3 (3.6)  6 (4.1)  4 (7.7)   
32. Avoiding the sun during the middle of the day (12-4 pm) is the most effective way of protecting the skin from the sun          .420 
False  40 (14.1)  14 (16.7)  17 (11.5)  9 (17.3)   
True  244 (85.9)  70 (83.3)  131 (88.5)  43 (82.7)   
33. Avoiding excessive exposure to sunlight before the age of 18 reduces the risk of skin cancer by 80%          .442 
False  86 (30.3)  22 (26.2)  45 (30.4)  19 (36.5)   
True  198 (69.7)  62 (73.8)  103 (69.6)  33 (63.5)   
34. Once my skin is tanned I no longer need to use sun protection measures          .721 
False  282 (99.3)  83 (98.8)  147 (99.3)  52 (100)   
True  2 (0.7)  1 (1.2)  1 (0.7)   
a

The data are expressed as means (SD) and frequencies (%).

b

Linear association test

Older students and students with more years of study had significantly fewer burns (P <.001 for age and academic year). Even so, 50.6% of the students in sixth year reported at least 1 sunburn episode in the previous year. Altogether, 80.9% of men reported at least 1 sunburn as compared to 66% of women (P=.003).

The skin color most associated with sunburn was fair (41.6%), although this difference was not statistically significant. Students with low skin phototypes reported fewer sunburns in the previous summer (P <0.001).

The attitudes that correlated most closely with sunburn frequency were “It is worthwhile using sunscreen even though it stops me from tanning”, (P <.001), “Sunbathing is healthy for my body”, (P=.029), and “I dislike high protection factor sunscreens because they look unattractive”, (P=.010). Sunburn frequency was not associated with the percentage of correct answers in the knowledge section, except in the case of the statement “Sunscreens prevent skin aging caused by the ultraviolet radiation in sunlight”, (P=.031).

Multivariate Analysis

The variables that were statistically significant in the univariate analysis were included in both the logistic analyses (Table 3).

Table 3.

Multivariate Logistic Regression.

  Low Grade Burns vs No BurnHigh Grade Burns vs No Burn
  P  OR (95% CI)  P  OR (95% CI) 
Age, by year  .001  0.85 (0.77; 0.94) 
Male sex  .019  2.24 (1.14; 4.38)  <.001  6.83 (2.23; 20.89) 
Academic year         
1st (Ref.) 
3rd  .526  0.68 (0.21; 2.22) 
6th  .002  0.09 (0.02; 0.42) 
2. Skin phototype         
Phototype I (Ref.)   
Phototype II  .542  1.59 (0.36; 7.09) 
Phototype III  .010  0.14 (0.03; 0.62) 
Phototype IV  .003  0.07 (0.01; 0.40) 
19. It is worthwhile using sunscreen even though it stops me from tanning, by academic year.      .014  3.37 (1.28; 8.90) 
27. I dislike high protection factor sunscreens because they look unattractive, by academic year.  .012  0.50 (0.29; 0.86) 

The variables that showed an independent, statistically significant association with a low sunburn frequency (1-2 episodes) were age (OR per year=0.85) and male sex (OR=2.24). The variables that showed an independent, statistically significant association with a high frequency of sunburn (≥ 3 episodes) were male sex (OR=6.83), academic year (sixth year students had a lower risk of sunburn compared to those in their first year [OR=0.09]), skin phototype (respondents with skin phototype I reported fewer sunburn episodes than those with skin phototype III [OR=0.14] or IV [OR=0.07]), “It is worthwhile using sunscreen, even though it stops me from tanning” (for each level of disagreement [OR=3.37]), and “I dislike high protection factor sunscreens because they look unattractive” (for each level of disagreement [OR=0.50]).

Discussion

The most significant finding in this study was the very high frequency of sunburn in this population, when one would expect that sunburn frequency would, at least, be lower in medical students than in the general population. Despite the lower sunburn frequency among students with more years of study, half of the final year students continue to report at least 1 sunburn every summer. Moreover, students’ attitudes and knowledge remain almost unchanged throughout their studies.

Using the same questionnaire in an adolescent population living in the Costa del Sol area, Fernández-Morano et al. observed a sunburn frequency of 74.4%.10 During the validation of this questionnaire in a population aged under 14 years living in southern Spain, this percentage was 43.3%,9 and a similar frequency (46.9%) was reported in a study carried out on the beach in the Costa del Sol area.8 Another study carried out on the beach in Valencia reported a history of sunburn in 70% of respondents, with a higher frequency among adolescents and young adults.13 This was is the first validated study on sun exposure habits carried out in the Canary Islands. The possibility of practically year-round sunbathing in our area would explain a greater sunburn frequency than in the population of the Iberian peninsula. In other studies in university students, Lopez-Ravello et al. observed a sunburn frequency of 88.2% in students of the University of Granada.12 Yurtseven et al. studied students attending the University of Istanbul, 39.6% of whom reported having a sunburn episode at least once in their lives.16 The authors of another study observed a lack of knowledge and incorrect sun exposure habits among students attending the Faculty of Physical Education and Sports Sciences at the University of Granada but did not investigate history of sunburn epidsodes.17

Both age and academic year showed an independent association in the multivariate analysis. The risk of sunburn decreased as the students advanced in their studies. This decline could be explained by the lack of maturity and scant awareness of the risk of disease among younger people.18 Another reason for the decline could be that as students advance in their studies, their medical knowledge increases and they become more aware of the medical facts, and place a greater value on their own health. Despite this, the percentage of sixth year students in our study who reported sunburn episodes was high.

In our study, male sex was associated with sunburns, but the data on this association in earlier studies in inconsistent.8,10,13 Our finding could be due to the fact that the women used more sunscreen and products that had a higher SPF. In a literature review on skin cancer prevention published by Stanton et al. in 2004, several of the articles included indicated that men and young people are at greater risk of sunburn. Those authors also noted that women were more knowledgeable about skin cancer and tended to exhibit more protective behaviors. This is in contradiction with the fact that women are more likely than men to perceive tanning as desirable,11,13 a finding confirmed in our study.

In our study, a low skin phototype was a protective factor, by contrast with the results of other studies in which phototypes I, II and III are compared with phototype IV.8 Probably students with phototypes I and II have suffered severe sunburn in the past and are more aware of the need for protective habits and measures, while individuals with higher skin phototypes do not make adequate use of sunscreens or use them to increase the length of exposure to the sun.11,19,20

In our study and in those mentioned above,8–13,16 the photoprotection measure most often used were topical sunscreens. The statement “It is worthwhile using sunscreen even though it stops me from tanning” was negatively associated with sunburn. The statement “I dislike high protection creams because they look unattractive” was positively associated with sunburn. These findings highlight the importance of developing cosmetically acceptable, high SPF topical sunscreens that are easy to apply and would facilitate adherence to sun protection measures in the general population.

The percentage of knowledge questions answered correctly was very high, and this did not vary across the 3 academic years. In spite of this, the students expressed positive attitudes toward sun exposure and reported inadequate use of photoprotection, a phenomenon that has already been described.13,19 The authors of a study of Australian adolescents concluded that a high level of knowledge is not related to the adequate use of photoprotection and that attempts to modify attitudes and behaviors in adolescents have limited success.21 The question with the lowest percentage of correct answers was perhaps the most specific: “Avoiding sun exposure when you are young (before 18 years of age) reduces the risk of skin cancer by 80%.” Prevention campaigns tend to focus on the overall risk of skin cancer and not emphasize that children and adolescents are the population in which the impact of exposure on the future of skin cancer is greatest.

The main limitation of our work is that the study population was geographically and sociologically delimited, so the data cannot be extrapolated to the population as a whole. Moreover, it was a cross-sectional study based on a questionnaire which, although specifically designed and validated for this type of study, may be susceptible to memory bias or a desire to provide socially desirable answers. Our work does show that a thorough knowledge of the risks of sun exposure and its relationship with skin cancer is not necessarily associated with proper preventive behaviors or a lower frequency of sunburn, even in a presumably sensitized population, such as a group of medical students including those who have completed 6 years of advanced studies and have studied skin disease.

Conclusions

Our findings, obtained in a selected population with the maximum possible knowledge about sun exposure, suggest that photoprotection campaigns should focus more on modifying attitudes than providing knowledge. To do this, they need to influence the population at a younger age and look for other possible strategies, such as using social referents (athletes, actors, or singers) as models.21 At the same time, the current aesthetic model needs to be modified because darker skin tone is still synonymous with beauty.

Conflicts of Interest

The authors declare that they have no conflicts of interest.

Acknowledgments

We would like to thank Dr. Buendía Eisman (Department of Dermatology, University of Granada) for his advice during this study.

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Please cite this article as: Ponce S, Jódar A, Borrego L, Saavedra P. Comportamientos, actitudes y conocimientos relacionados con la exposición solar en estudiantes de medicina de la Universidad de Las Palmas de Gran Canaria . Actas Dermosifiliogr. 2019;110:372–384.

Copyright © 2018. Elsevier España, S.L.U. and AEDV
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